Treating Plaque Psoriasis: Finding the Right Option

Psound Bytes™ Transcript: Episode 203

Release date: August 22, 2023

“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”

Shiva: My name is Shiva Mozaffarian and joining me for a discussion about treating plaque psoriasis during Psoriasis Action Month is dermatologist Dr. David Rosmarin, Chair of the Department of Dermatology at Indiana University School of Medicine where he is also an Associate Professor of Dermatology and the Kampen-Norins Scholar in Dermatology. Dr. Rosmarin directs the psoriasis clinic at Indiana University Health and has a passion for treating inflammatory skin conditions which includes psoriasis along with conducting clinical research to find new treatment options.

Thank you Dr. Rosmarin for joining Psound Bytes™ today! Let’s start with a few questions about plaque psoriasis which is the most common type of psoriasis. What are the characteristics and symptoms of plaque psoriasis, and how will someone know they have plaque psoriasis and they need to see a health care provider or a dermatologist such as yourself?

Dr. Rosmarin: So plaque psoriasis effects anywhere from 2 to 5% of the US population and plaque type is the most common. Less common variants include guttate psoriasis, palmoplantar psoriasis. Some patients just have it on the scalp, some people are erythrodermic meaning they have it head to toe. And symptoms really vary. Some may be asymptomatic, they may not have any symptoms. Others can experience itch and psoriasis has a tendency to be quite itchy if it's on the scalp. Some people have a lot of itch though on the lower legs or in other locations. Some people who have psoriasis, particularly on the hands or feet, it can be really painful. If there are cracks and fissures in the psoriasis oftentimes that can lead to pain and difficult in manipulating objects. People who have their nails involved also can be quite painful and uncomfortable, particularly with manipulating objects as well. So symptoms really vary from having nothing at all to being uncomfortable, to having frank pain and having itch. In terms of when to see a health care provider, if it's affecting your quality of life. So if the psoriasis is bothering you because of one of the symptoms you're having, you should see a health care provider. If the psoriasis is bothering you because of the way it looks, you should see a health care provider. Our goal is to make it so that the psoriasis is not affecting your quality of life at all. 

Shiva: Definitely! And will plaque psoriasis look different on someone with skin of color?

Dr. Rosmarin: So psoriasis can look different depending on the background skin color. So oftentimes when the skin is darker, it's harder to appreciate the redness or erythema, and also people who have darker skin tones are also more at risk for post inflammatory, hyper or hypopigmentation. So after the psoriasis goes away, they can be left with dark marks in particular, and sometimes even lighter marks, and that can also be disfiguring as well. We have to be more cognizant of that post inflammatory color change in skin of color.

Shiva: So why does plaque psoriasis occur and who’s more likely to be diagnosed with plaque psoriasis? You know some people could live years without psoriasis and then all of a sudden be diagnosed with the disease in their fifties or sixties. So why is that?

Dr. Rosmarin: Psoriasis is a disease where the immune system is too active in the skin and the immune system, is meant to fight off infections, bacteria, viruses, fungus. But sometimes it becomes active in the absence of infection, or because there was an infection and that can lead to these red, scaly plaques that we see on the skin. Now, we're not sure what the trigger is. In some people it could be a medication, in some it could be trauma, in others it could be sunlight. But there's something that can trigger it in individuals that leads to this overactive immune response. And once you have psoriasis, we can't cure it. We can control it, but we can't cure it. We can't make it go away forever. It's a lot like high blood pressure or high cholesterol where we can't ever cure the high cholesterol or high blood pressure but we can control it with treatments. Now most commonly, people get psoriasis around their 20’s, and then there's a second peak of when people are getting psoriasis around the 60s or so. And it's often less severe when people get it and they're a little bit older. Having said that, people can get it at any age. Infants can get it, although that's not as common, and people at any age are at risk for getting psoriasis because something can trigger it. We're not always sure what that is.

Shiva: And Dr. Rosmarin, is it possible plaque psoriasis could be confused with other diseases? How is plaque psoriasis diagnosed and are there any specific tests used to diagnose the disease? 

Dr. Rosmarin: Psoriasis is in a category of diseases that we call papulosquamous. Papulo, meaning raised and squamous being scaly. So there are a hundred of other diseases that fall into that category that are papulosquamous or red and scaly. Plaque psoriasis is one of them. Lichen planus is another which is a little bit more purple, tends to affect more the wrists and ankles, can have a different type of scale to it that's more net like. Often times it's very itchy and there are other diseases as well. Sometimes tinea corporis or a fungal infection in the skin can also be red and scaly, and there are other diseases as well that fall into that category. And when you see a dermatologist, they're looking at how the redness and scale looks on the skin. Is it well demarcated? What are the locations of the psoriasis? What are the symptoms and that helps largely with the diagnosis. If a dermatologist isn't sure, they may do some tests to find out. For example, if the dermatologist is concerned about a fungal infection, they may do a scraping and staining it with potassium hydroxide or KOH to see if there's fungus under the microscope. Another common way that we help confirm the diagnosis of psoriasis is with the biopsy, where the skin is numbed up with a little numbing medicine, and then a small sample is taken to be looked at under the microscope to see if it looks like psoriasis and that helps distinguish it from other diseases like eczema. 

Shiva: So once psoriasis is diagnosed, how will severity of disease impact selection of treatment options?

Dr. Rosmarin: So the treatment of psoriasis is really patient dependent. As dermatologists we treat patients, not diseases. So if the psoriasis is not impacting somebody's quality of life, we may not treat it and we may just let the patients live their life normally. However, for many it does affect their quality of life and I often divide patients into two categories, topical responders and topical non-responders. There are some patients who can use some topical medication on their elbows and knees if they have a low body surface area typically and have very good responses.  There are other patients who they try that and then that's not enough. And rather than keep cycling between multiple different topical regimens, we may want to use light treatment, pills, and biologic therapy. But the key is that we treat patients, not diseases. So what's right for one patient may not be right for the next patient. Our main goal is to improve somebody's quality of life.

Shiva: And can you define for us what body surface area means with regards to mild, moderate, or severe psoriasis?

Dr. Rosmarin: So oftentimes you'll hear these terms of mild, moderate, or severe psoriasis and it's hard to define because it can be very patient dependent. One way to do that is by looking at the body surface area, or BSA. Patients who have zero to 3% of their body affected, we often consider mild. In the three to five to up to 10%, we may call moderate, and 10% or more we’ll call severe. Now, having said that, it's very patient dependent because a patient may have a very low body surface area but have involvement on the genitals or their scalp or their hands and feet. But they're severely affected by their disease. So we have limitations by using that body surface area definition for how we define mild, moderate, or severe psoriasis. In terms of when I'm using percent body surface area of psoriasis, the patient's own hand is considered 1%. So that's often how we think about it. So 3 of a patient's hand would mean 3% body surface area.

Shiva: You alluded to this already but could you provide more detail about what happens if someone presents with mild plaque psoriasis. What would management of the disease include?

Dr. Rosmarin: If a patient has mild psoriasis, they should ask themselves, is this bothering them or not? If it's not affecting their quality of life, if they just have a little bit on their elbows and they feel like it doesn't bother them at all, then they don't need to intervene. However, if it's causing them to wear long sleeve shirts and not go to the beach, or they feel self-conscious about it, well then they need to discuss it with their dermatologist. Oftentimes, when a low body surface area is involved, we'll start off with topical management and that can include topical corticosteroids, vitamin D analogs, and some of our newer treatments as well, including a phosphodiesterase 4 inhibitor and a aryl hydrocarbon receptor agonist. All of these different classes of treatments can be quite effective at treating psoriasis.

Shiva: So can over-the-counter products be used with prescription medication to help diminish some of the symptoms, like the itch you mentioned before, and if so, could you provide some examples of these products?

Dr. Rosmarin: Sometimes we'll recommend using moisturizers, that can be helpful for patients with psoriasis. Classes of medicine called keratolytics, which can help take off some of the scale, can be helpful and those are ingredients with salicylic acid, urea, or lachydrogen. Those are all medicines that can help, especially if the skin is really thick. That can help take the edge off, and so those are oftentimes what we're recommending for over the counter treatments. Another option that patients can do at home is getting a little bit of sun and we have to be careful of recommending that as dermatologists because sunlight can in fact help the psoriasis, but we also don't want to raise the risk of skin cancer in the patients. So the phototherapy that we may give in an office booth is different than what you're getting from natural sunlight. And we much prefer to use phototherapy that we can give in an office booth with a specific wavelength of light, then getting natural sunlight. 

Shiva: So let's say for example a woman in her 30’s comes in to see you with mild psoriasis on her face and moderate plaque psoriasis on her scalp. Because of the locations she’s really upset and concerned about her appearance. What would you recommend to treat this plaque psoriasis?

Dr. Rosmarin: So the first comment I would make is that even though it may be mild by definition due to body surface area, this is not what I would call mild psoriasis because it's really affecting this patient's quality of life. It's having a moderate-to-severe effect and we want to do everything we can to get that patient better. Now we may start off by using a topical regimen and we may want to avoid topical corticosteroids on the face or limit their use, because corticosteroids can cause a lightning or thinning of the skin, and the facial skin is thinner and more sensitive so we have to be more careful about that side effect. Additionally, the scalp, we have to be careful because its skin is very thick so if we give the same treatment as we're giving for the face, it may not work for the scalp. So those are important considerations in mind and we may want to use a medication such as a pill or a biologic to help get the face and the scalp clear. Some of our treatments now we can do them with a very high percent of success rate and really with minimal side effects. So what I would tell that patient is that we do have a lot of great options in terms of pills and biologic treatments that the patient can use should our topical regimens fail. And we would probably use something different for the face than for the scalp topically. 

Shiva: So it sounds like a combination of treatments then.

Dr. Rosmarin: So for topically we’ll use more than one treatment for the face and for the scalp. And often times if we're using a pill or a biologic, the patient may not need to use a topical treatment, but they can still use a topical with those systemic agents.

Shiva: Thank you Dr. Rosmarin for your insights about treating plaque psoriasis. For our listeners, stay with us as I continue my discussion with Dr. Rosmarin about current and upcoming treatment options for plaque psoriasis after this short announcement from CeraVe about products you can use for your psoriasis.

Thank you to our Psoriasis Action Month Sponsor, CeraVe. CeraVe has several products – CeraVe Psoriasis Cleanser & CeraVe Psoriasis Moisturizing Cream - that have earned the National Psoriasis Foundation Seal of Recognition listed in the Product Directory at psoriais.org/seal-of-recognition/.  Developed with dermatologists, all CeraVe products are formulated with 3 essential ceramides to help maintain and restore the skin’s natural protective barrier, reinforcing healthy skin for all. CeraVe is the #1 dermatologist recommended skincare brand in the U.S., and a proud sponsor of the National Psoriasis Foundation.”

Shiva: Welcome back everyone! Dr. Rosmarin, before our short break we spoke about use of topicals, over-the-counter products, and briefly about use of a biologic. You also mentioned phototherapy and use of the sun briefly. How effective is phototherapy for the treatment of plaque psoriasis and are there any restrictions that impact it’s use?

Dr. Rosmarin: So phototherapy is a standard treatment for plaque psoriasis. It can work quite well. Some of the downsides are that it's not great to use over hair bearing areas like the scalp. If the hair is blocking the penetration of the light, it's not gonna be of much use. Additionally, it can be very inconvenient for patients as well. So part of the challenge with psoriasis is not just the effects of the psoriasis, but the cost of the treatment to the patient. If the patient has to come in two or three times a week to an office, well, we're not doing much good for our patients if that's inconvenient for them. So we have to keep that that in mind as well. Phototherapy, though, can be quite a good treatment for our patients and has a very good safety profile and a good track record. We have a long history of using it with success in psoriasis.

Shiva: And is home phototherapy an option?

Dr. Rosmarin: Home phototherapy is a great option. It can be challenging to get insurance companies to pay for it, but it's much more convenient to have a home phototherapy booth than to have to go into an office to use it. One strategy that we often use is we'll have patients come into the office and if it's successful, we'll then say to insurance companies, this patient’s had success using in office phototherapy. Now, will you cover phototherapy for the patient to use at home? And sometimes we can get insurances to cover it for patients and many are very happy with that.

Shiva: Yeah, I imagine that would be really helpful. So I want to take some time to also talk about systemic treatments which you mentioned earlier. What oral medications are typically used to treat plaque psoriasis?

Dr. Rosmarin: Some of our traditional psoriasis medications include oral vitamin A treatments such as retinoids, like Acitretin (brand name of Soriatane) that often thins the plaques out and can be a useful treatment, particularly for palms and soles. Also, we can use it in conjunction with phototherapy as well to help get additional benefit. If we're thinning out the plaques and reducing the scale, then the light treatment can work better. Other treatments that we use for psoriasis are methotrexate, which is a very traditional treatment that's taken once a week but does have side effects. Very important not to drink alcohol with it. We have to monitor the liver. And it certainly can be effective for many patients, although not as effective or as safe as some of our newer options. We also have cyclosporin which can be quite effective and work very rapidly. We'll often use that if a patient is in crisis or as a bridge to other treatments, but the cyclosporine is never a long term option because with continued use it can cause high blood pressure and damage to the kidneys. So we would never use cyclosporine for more than a year and we really try to limit its use to under a few months. We also have two newer oral agents for plaque psoriasis, apremilast (brand name of Otezla) as well as Sotyktu or deucravacitinib which is a TYK2 inhibitor, and both of those have more favorable safety profiles and can be quite effective for the treatment of plaque psoriasis.

Shiva: And when would you consider use of a biologic or biosimilar? Can you address what types of biologics or biosimilars are available to treat plaque psoriasis?

Dr. Rosmarin: So I will consider a biologic or biosimilar for a patient if they are topical non-responders or a topical is not indicated - so if they have severe disease.  I think it's important to categorize patients into again topical responders or topical non-responders and not go through a set algorithm where we'll always do a topical first, then phototherapy, then a pill, then a biologic. Some patients should get biologic at their first visit. These can be highly effective and many of them have very good safety profiles as well, and they make a difference in patient’s quality of life. We don't want patients to wait many months on treatments that have low likelihood of success. We have multiple different classes of biologics. One of our earlier classes are the TNF alpha inhibitors, which are quite good for psoriasis and psoriatic arthritis, and we have multiple in that category. We also have anti IL-17 treatments which are very rapid medicines, very effective for both psoriasis and psoriatic arthritis. We have anti IL-23 medications as well. And to give you some examples, Skyrizi, Tremfya, Ilumya. Those are all anti IL-23’s. The injections are infrequent. They're only every two to three months. Even though injections may sound scary, these injections usually are fairly painless for patients and they hardly notice that they're injecting themselves, and they have very, very high efficacy and very good safety profiles. So those are great treatments for patients if they are not responding to topicals or the topicals aren't indicated. One of our new anti IL-17 medications that we’re hoping for approval soon is called Bimekizumab (brand name of Bimzelx) and that's truly exciting because it seems to have very, very high efficacy and be highly effective for psoriatic arthritis. So if there are patients out there that haven't responded to other treatments and feel like they've tried multiple biologics, Bimekizumab may be a terrific option because of its very, very high efficacy.

Shiva: Yeah, certainly glad to hear Bimekizumab now has a brand name.

Dr. Rosmarin: Bimekizumab is currently marketed outside of the United States, so we have the brand name from outside of the US.  It's not yet FDA approved. 

Shiva: So we know psoriasis is a wax and wane disease.  Is it possible to avoid flares of the disease? 

Dr. Rosmarin: Psoriasis can have periods when it's worse, and periods when it's better. Often times, patients notice that when the summertime comes up because of the natural sunlight, the disease improves, and in the wintertime it may worsen. There are others, though, that psoriasis is just bad year round. Also some people note that when they take certain medications, they're psoriasis flares. For example, one such medication is hydroxychloroquine or Plaquenil. And what we noticed was during the height of the COVID-19 pandemic, when we initially thought that Plaquenil might help with COVID and many patients went on that medicine, there were some worsening of psoriasis and some more cases of new onset psoriasis which is attributed to that medication. Additionally, when patients get infections such as a strep infections, but really any infection that can also worsen somebody’s psoriasis. And while light treatment can be helpful for the treatment of psoriasis, if patients get too much light or get a sunburn that can act like a traumatic event and also worsen the psoriasis.

Shiva: So what I’m hearing is it’s not really possible to avoid these flares.

Dr. Rosmarin: It's very hard to avoid flares.

Shiva: So treatments are ongoing.  Do you have any other tips you can offer to help someone manage their plaque psoriasis? Will lifestyle changes help?

Dr. Rosmarin: So in terms of lifestyle, it's always a good idea to eat a healthy diet, to exercise. Patients who have psoriasis are at higher risk for cardiovascular disease. So it's really important to take care of one’s overall health and take a holistic approach. However, oftentimes when it comes to treating the psoriasis plaques themselves, it requires medical management with topicals, orals, phototherapy or biologics.

Shiva: Thank you so much Dr. Rosmarin, for being here with us today to discuss treating plaque psoriasis. Do you have any final comments you'd like to share with our listeners today?

Dr. Rosmarin: Thank you, Shiva. I've enjoyed being here today discussing psoriasis with you. My main message is that we have a lot of options out there. Psoriasis is different today than it was 30 years ago, and patients don't have to suffer. If you're out there and psoriasis is still impacting your quality of life, see your dermatologist. The National Psoriasis Foundation has a list of providers that are particularly adept at treating patients with psoriasis. And we have a bunch of different options that can really help with the quality of life. Be it those different options such as topicals, phototherapy, pills, or biologics. We can almost always find the right option for the right person. 

Shiva: That's such a good message to close out our episode. Thank you again Dr. Rosmarin for being here today and for providing such interesting information about treating plaque psoriasis! For our listeners, August is Psoriasis Action Month. Learn more about plaque psoriasis and what your treatment options are by contacting our Patient Navigation Center to request the free “PsO Action Month” Kit by calling (800) 723-9166 or by emailing education@psoriasis.org.  And finally, thank you to our sponsors who provided support on behalf of Psoriasis Action Month activities through unrestricted educational grants by CeraVe and Novartis.

We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Google Play, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.  

This transcript has been created by a computer and edited by an NPF Volunteer.